Emeka Chukwusa

Background: There is growing evidence that air pollution may impact mental health, however this is the first study to investigate its role in child and adolescent community mental health service use. Methods: This retrospective cohort study used electronic health records from a large South London mental healthcare provider to establish a cohort of young people first in contact with community mental health services between 2008 and 2012, who were then followed for up to 9 years. Baseline (3-month) residential nitrogen dioxide (NO2), particulate matter (PM)10 and PM2.5 exposure was estimated using the KCL urban model. Contacts over 1-, 5-, and 9-year periods were analysed in relation to air pollution using negative binomial regression. The potential effect-modifying role of high vs low greenspace exposure (residential normalised difference vegetation index) and age-, gender-, ethnicity- and disorder-specific differences were investigated using subgroup analyses. Findings: The sample consisted of 11,773 children and adolescents (3-17 years) who had first face-to-face contact with mental health services between 2008 and 2012. Consistent positive associations were observed between air pollution exposure and number of community mental health service (CMHS) contacts. For example, by Year 9 a clear dose-response pattern was evident between NO2 exposure and CMHS contacts, with an adjusted incidence rate ratio of 1.17 (95% CI=1.09 to 1.26) for service users in the highest quartile of exposure compared to the lowest quartile. Population Attributable Fractions (PAFs) suggested that bringing UK air quality in line with WHO recommendations could reduce CMHS contacts by 3-6%. Associations were most pronounced for boys and children (3-12 years) and were substantially attenuated in those living near high levels of greenspace. Interpretation: Residential air pollution exposure was associated with increased community mental health service contacts in children and adolescents, attenuated by high greenspace exposure, suggesting that policy changes acting on air quality and green infrastructure in urban settings could improve population-level mental health and reduce current strain on child and adolescent mental health services.

Background: Emerging evidence suggests that extreme heat is associated with negative outcomes mental health outcomes. However, little known about its impact on wider mental health service use amongst individuals with pre-existing mental illness.Method: We gathered data on daily counts of inpatient admissions and community mental health team (CMHT) contacts during the summer from the mental healthcare provider from two large mental health trusts in London serving more than 1.8 million people between 1 January 2008 and 31 December 2019. These data were linked with 1km x 1km daily temperature estimates derived from the HadUK-Grid, a gridded climate dataset. We applied a time-series design using a conditional Poisson regression combined with a distributed lag non-linear model (DLNM) to estimate the associations between exposure to extreme heat (defined as 99th percentile of summer temperature) and admissions and CMHT contacts. We conducted subgroup analyses across diagnostic groups and assessed effect modification by residential greenness (measured by Normalised Difference Vegetation index, NDVI) and air pollutants, including particulate matter (PM2.5) and nitrogen dioxides (NO2).Findings: The study included 2,061,378 inpatient admissions and 2,054,401 CMHT contacts. There was evidence that exposure to extreme heat was associated with a 6% increase in admissions (RR: 1.06, 1.04 - 1.08) but not with CMHT contacts (RR: 1.07, 0.97 − 1.18). Subgroup analysis showed differential effects across a wide spectrum of clinical needs and diagnosis groups. Higher levels of residential greenness significantly mitigated the impacts of extreme heat on admissions. The impacts of extreme heat also appeared to be amplified by higher levels of PM2.5 and NO2, although these interactions did not reach statistical significance.Interpretation: Extreme heat has heterogeneous effects on mental health service use across diagnostic subgroups. Residential greenness mitigates the impact of extreme heat on admissions. An integrated mitigation strategy that addresses extreme heat through residential greening is likely to reduce its burden on individuals with mental illness.

Background: Minority ethnic populations face persistent inequities in end-of-life care, yet research often fails to capture these disparities due to methodological limitations. Robust approaches are urgently needed to investigate and address these inequities. Aim: To develop best practice principles for conducting qualitative and quantitative research on ethnicity in palliative and end of life care. Design: We conducted a modified Delphi study online, comprising one qualitative round and two quantitative rounds. Round 1 collected open-ended responses to generate 97 statements. In rounds 2 and 3, participants rated these on a 5-point Likert scale; statements were retained if ⩾75% rated them ‘very’ or ‘extremely important’. Consensus statements informed the development of guiding principles, which were further refined during a stakeholder workshop. Participants were UK-based and included minority ethnic patients, carers, community representatives, researchers, health professionals, and palliative care specialists. Results: Forty-five participants completed round 1, 43 round 2, and 45 round 3. Of 97 statements, 78 (80%) reached consensus in round 2, and all 78 (100%) in round 3. Seventeen stakeholders attended the workshop, resulting in 13 consensus-based guiding principles. Conclusions: This UK-based Delphi established 13 key principles to strengthen research involving minority ethnic populations in palliative and end-of-life care. Implementing these principles will help address inequities and improve the quality and impact of future studies, with validation needed in international contexts.

Background: Geographic variations in end-of-life healthcare utilisation may highlight disparities in access to care, including palliative care. Studies demonstrate that place of death and palliative care utilisation are influenced by geographic exposures such as sociodemographic and socioeconomic characteristics, rurality, and health service availability. No systematic review has synthesised the evidence across multiple geographic exposures. This is important to provide conclusions from a broader evidence base and inform equitable commissioning of palliative care services. Aim: To investigate the influence of geographic exposures on individual-level place of death and palliative care utilisation in the last three months of life, to identify potential disparities in end-of-life healthcare provision. Methods: In this systematic literature review of quantitative data with narrative synthesis, nine databases were searched for peer-reviewed observational studies published between 1st January 2004 and 1st October 2024. Eligible studies recruited adults in high-income countries and compared two or more geographic exposures. Methodological quality was assessed using the Newcastle-Ottawa Scale. Results: Of 9,296 studies identified, 51 retrospective studies across 24 countries were included. Rurality was positively associated with home death and decreased palliative care utilisation. Regarding healthcare availability, greater bed availability in hospital or long-term care facilities increased likelihood of death in that facility. Similarly, closer proximity to a hospice or hospital location increased likelihood of death in that facility. Hospital death may be positively associated with residence in certain countries, regions of high population density, and those containing capital cities. Conclusions: Findings highlight geographic variations as areas of focus for commissioners and policymakers to reduce local end-of-life healthcare inequities. We make recommendations regarding structural care gaps, service efficiency, and innovation in palliative care provision. Protocol registration: Prospero registration number CRD42019154912.

Background Improving access to opioids in Latin America requires better understanding of prescription patterns in palliative care. Aim To describe opioid prescribing patterns, including types and doses in morphine equivalent daily dose (MEDD), among patients receiving palliative care, including patients with cancer and non-cancer conditions in Latin America. Design Systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data sources We searched MEDLINE, EMBASE, PubMed, LILACS and SciELO from inception to January 2025. Quantitative studies reporting opioid prescriptions in adult patients receiving palliative care were included. Two reviewers independently screened, extracted data and assessed methodological quality using the Effective Public Health Practice Project tool. A narrative synthesis and descriptive statistics were conducted. Meta-analysis of MEDD was performed post hoc using random-effects models. Results Of 2855 records, 51 studies from seven countries met inclusion criteria. Most were observational (75%), with 8641 patients analysed. Cancer pain was the main indication (98%). Morphine (61%) and tramadol (15%) were the most frequently prescribed opioids. A meta-analysis of 48 studies (8433 patients) yielded a pooled mean MEDD of 98.06 mg (95% CI 77.07 to 119.05), with substantial heterogeneity (I²=100%). Most studies were rated as low to moderate quality. Conclusions This review provides a regional synthesis of opioid prescribing patterns for palliative care in Latin America. Although morphine is the most used opioid, data show limited dosing variability and a scarcity of high-quality studies. Strengthening research capacity is essential to inform clinical guidelines and policy for equitable and adequate pain management in palliative care across the region. PROSPERO registration number CRD42024497564.

Introduction: Studies suggest that extreme heat events can have negative effects on mental health. However, characterisation of these effects in urban communities remains limited, and few studies have investigated the potential modifying effects of demographic, clinical and environmental characteristics. The aim of this study is to address this knowledge gap and quantify the impacts of extreme heat on mental health, health service use and mental well-being in vulnerable urban populations. Methods and analysis: In this multidisciplinary project, we will assess mental health outcomes in different populations by bringing together two distinct datasets: electronic health record (EHR) data on mental health service users and data from general public participants of Urban Mind, a citizen science project. We will use EHRs from the South London and Maudsley NHS Foundation Trust (SLaM) and the North London NHS Foundation Trust (NLFT), from six boroughs which collectively cover more than 1.8 million residents in Greater London, to capture mental health service use and mortality among people with existing diagnoses of mental illness across 2008–2023. We will use smartphone-based ecological momentary assessment data from Urban Mind to measure mental well-being in the general population (2018–2023). These datasets will be linked to high-resolution spatiotemporal data on temperature, fine and coarse particulate matter (PM _2.5 , PM ₁₀ ), nitrogen dioxide (NO ₂ ), Normalised Difference Vegetation Index (NDVI) and density of large mature tree canopy. We will employ novel quasi-experimental designs, including case time series and case-crossover analysis, to examine the impact of extreme heat on mental health and explore effect modification by sociodemographic, clinical and environmental factors, including air pollution and types of green space coverage. We will also develop a microsimulation model combined with the InVEST urban cooling model to assess and forecast the mental health and social care impacts of extreme heat events and the mitigation of these impacts by different green space coverage and pollution-reduction policies. With a core team composed of researchers, community organisations, industry partners and specialist policy experts, this project will consider lived experience, benefit from broad stakeholder engagement and address gaps in policy and practice. Ethics and dissemination: Each component of this project has been approved by the relevant ethics committee (ref RESCM-22/23-6905 for Urban Mind, LRS/DP-23/24-41409 for the co-development of a screening tool, 23/SC/0257 for the SLaM EHRs, and 24/EE/0178 for the NLFT EHRs). Our dissemination plan includes peer-reviewed scientific articles, policy briefs, a practical guide on fostering ecological and human resilience at the neighbourhood level, and a technical guide for planting and improving the growing conditions of large canopy trees.

Background: High rates of hospital admissions have been reported for patients with mental illness, but less is known about factors associated with multiple hospitalisations at the end-of-life in this group. Aim: To describe the geographical variations in end-of-life hospitalisations and examine factors associated with multiple hospitalisations (≥ 2) in the last 90 days of life for people with mental illness. Methods: A national population-based observational study in England UK using a linkage of Hospital Episode Statistics Admitted Patient Care (HES-APC) and the Office for National Statistics (ONS) death registry data. Our cohort comprised patients aged 18 and over, who died in England between 2018-04-01 and 2019-03-31 with HES-APC diagnoses of (1) Schizotypal, delusional disorders or schizophrenia, (2) schizoaffective or bipolar affective disorder, (3) substance use disorders; or (4) depressive episodes or recurrent depressive disorders. Geographic variations of end-of-life hospitalisations for each diagnostic group were described across National Health Services (NHS) regions. Modified Poisson regression models were used to estimate factors associated with multiple end-of-life hospitalisations in each diagnostic group. Results: A total of 49,775 patients with mental illness died in the year 2018–2019, of whom 50.2% (n = 25,004) had multiple end-of-life hospitalisation in the last 90 days of life. Factors positively associated with multiple end-of-life hospitalisations included older age, being resident in an urban area, cancer related deaths, and, for patients with depressive disorders, higher socioeconomic deprivation. Conclusion: Strengthening primary and community care services targeted at older adults with cancer could potentially reduce multiple end-of-life hospitalisations for patients with mental illness.

Background: In Chinese traditional culture, discussions surrounding death are often considered taboo, leading to a poor quality of death, and limited public awareness and knowledge about palliative and end-of-life care (PEoLC). However, the increasing prevalence of social media in health communication in China presents an opportunity to promote and educate the public about PEoLC through online discussions. Objective: This study aimed to examine the factors influencing public engagement in PEoLC discussions on a Chinese social media platform and develop practice recommendations to promote such engagement. Methods: We gathered 30,811 PEoLC-related posts on Weibo, the largest social media platform in China. Guided by the elaboration likelihood model, our study examined factors across 4 dimensions: content theme, mood, information richness, and source credibility. Content theme was examined using thematic analysis, while sentiment analysis was used to determine the mood of the posts. The impact of potential factors on post engagement was quantified using negative binomial regression. Results: Organizational accounts exhibited lower engagement compared to individual accounts (incidence rate ratio [IRR]<1; P<.001), suggesting an underuse of organizational accounts in advocating for PEoLC on Weibo. Posts centered on PEoLC-related entertainment (films, television shows, and books; IRR=1.37; P<.001) or controversial social news (IRR=1.64; P<.001) garnered more engagement, primarily published by individual accounts. An interaction effect was observed between content theme and post mood, with posts featuring more negative sentiment generally attracting higher public engagement, except for educational-related posts (IRR=2.68; P<.001). Conclusions: Overall, organizations faced challenges in capturing public attention and involving the public when promoting PEoLC on Chinese social media platforms. It is imperative to move beyond a traditional mode to incorporate cultural elements of social media, such as engaging influencers, leveraging entertainment content and social news, or using visual elements, which can serve as effective catalysts in attracting public attention. The strategies developed in this study are particularly pertinent to nonprofit organizations and academics aiming to use social media for PEoLC campaigns, fundraising efforts, or research dissemination.

Objective To explore opioid prescribing patterns for cancer pain in Latin America (LA). Methods A systematic review was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Relevant databases, including MEDLINE, EMBASE, PubMed, LILACS and Scielo, were searched from inception to June 2023. Empirical studies of opioid prescription patterns in adult palliative care patients with cancer pain were included. Methodological quality was assessed using the Effective Public Health Practice Project tool. Data were analysed using narrative synthesis. Descriptive statistical analyses were conducted using SPSS V.28 (IBM). Categorical variables were summarised using frequencies and percentages and continuous variables as means or medians. Results Seventeen studies from six countries were included. Ten were observational, while seven were experimental, including five randomised controlled trials (RCT) and two non-RCT. Most were low or moderate methodological quality. Out of 7809 patients, morphine (54%) and tramadol (18%) were the most prescribed opioids. The median of morphine equivalent daily dose was 26 mg (IQR 26–41). Conclusion Latin America shows lower opioid consumption rates compared with high-income countries for control pain management (CPM). More rigorous research on CPM in LA is needed. Additionally, a comprehensive review of opioid prescription patterns, including non-cancer diagnoses, is necessary.

BACKGROUND In Chinese traditional culture, discussions surrounding death are often considered taboo, leading to a poor quality of death, and limited public awareness and knowledge about palliative and end-of-life care (PEoLC). However, the increasing prevalence of social media in health communication in China presents an opportunity to promote and educate the public about PEoLC through online discussions. OBJECTIVE This study aimed to examine the factors influencing public engagement in PEoLC discussions on a Chinese social media platform and develop practice recommendations to promote such engagement. METHODS We gathered 30,811 PEoLC-related posts on Weibo, the largest social media platform in China. Guided by the elaboration likelihood model, our study examined factors across 4 dimensions: content theme, mood, information richness, and source credibility. Content theme was examined using thematic analysis, while sentiment analysis was used to determine the mood of the posts. The impact of potential factors on post engagement was quantified using negative binomial regression. RESULTS Organizational accounts exhibited lower engagement compared to individual accounts (incidence rate ratio [IRR]<1; P<.001), suggesting an underuse of organizational accounts in advocating for PEoLC on Weibo. Posts centered on PEoLC-related entertainment (films, television shows, and books; IRR=1.37; P<.001) or controversial social news (IRR=1.64; P<.001) garnered more engagement, primarily published by individual accounts. An interaction effect was observed between content theme and post mood, with posts featuring more negative sentiment generally attracting higher public engagement, except for educational-related posts (IRR=2.68; P<.001). CONCLUSIONS Overall, organizations faced challenges in capturing public attention and involving the public when promoting PEoLC on Chinese social media platforms. It is imperative to move beyond a traditional mode to incorporate cultural elements of social media, such as engaging influencers, leveraging entertainment content and social news, or using visual elements, which can serve as effective catalysts in attracting public attention. The strategies developed in this study are particularly pertinent to nonprofit organizations and academics aiming to use social media for PEoLC campaigns, fundraising efforts, or research dissemination.